WHO declares Zika virus a threat of ‘alarming proportions’

Health authorities are on high alert to prevent a mosquito-borne virus linked to thousands of birth defects in South America getting a toehold in Australia.

Though there is no evidence the Zika virus, which health experts suspect has infected millions in Brazil and surrounding countries in recent months, has been transmitted in Australia, authorities are concerned about the possibility someone infected with the disease overseas may travel to central and northern Queensland, where mosquitos capable of carrying the disease are found.

“There is very low risk of transmission of Zika virus in Australia, due to the absence of mosquito vectors in most parts of the country,” the Health Department said, but added that “there is continuing risk of Zika virus being imported into Australia…with the risk of local transmission in areas of central and north Queensland where the mosquito vector is present”.

Australia’s preparations come amid mounting international alarm over the rapid spread of the virus and fears it is linked to an increased incidence of serious birth defects including abnormally small heads and paralysis.

World Health Organisation Director-General Dr Margaret Chan said the virus was “spreading explosively” in South and Central America since being first detected in the region last year, and the WHO’s Emergency Committee has been convened to consider declaring the outbreak a Public Health Emergency of International Concern.

The virus, which is closely related to the dengue virus, was first detected in 1947, and there have only ever been 20 confirmed cases in Australia – six of them in 2015 alone, and all of them involving infection overseas.

Only about 20 per cent of those infected with the Zika virus show symptoms, and the disease itself is considered to be relatively mild and only lasts a few days.

But there is no vaccine or treatment, apart from rest, plenty of fluids and analgesics, and Dr Chan said the speed of the virus’s spread and its possible link to serious birth defects meant the threat it posed had been elevated form mild “to one of alarming proportions”.

“The level of alarm is extremely high,” Dr Chan said. “Arrival of the virus in some places has been associated with a steep increase in the birth of babies with abnormally small heads and in cases of Guillain-Barre syndrome.

A causal relationship between Zika virus infection and birth malformations and neurological syndromes has not yet been established, but is strongly suspected.”

But there are concerns, yet to be scientifically verified, that the virus may cause microcephaly (small or under-developed brain) in unborn infants.

In Brazil, a four-fold increase in the number of cases of microcephaly last year coincided with widespread outbreaks of the Zika virus, increasing suspicions of a link.

An investigation by the Brazil Ministry of Health found that of 35 cases of microcephaly recorded in a registry established to investigate the outbreak, 74 per cent of mothers reported a rash illness during their pregnancy. More than 70 per cent of the babies were found to have severe microcephaly, and all 27 that underwent neuroimaging were found to be abnormal.

“The possible links, only recently suspected, have rapidly changed the risk profile of Zika, from a mild threat to one of alarming proportions,” Dr Chan said. “The increased incidence of microcephaly is particularly alarming, as it places a heart-breaking burden on families and communities.”

The Department of Foreign Affairs and Trade has issued a travel advisory recommending that pregnant women considering travelling to countries where the Zika virus is present to defer their plans.

“Given possible transmission of the disease to unborn babies, and taking a very cautious approach, pregnant women should consider postponing travel to Brazil or talk to their doctor about implications,” the Department said.

The Brazil outbreak has drawn particular attention given that hundreds of thousands of athletes, government officials and tourists are expected to travel to the country later this year for the Olympic Games.

DFAT has issued similar travel advice for all 23 countries where the virus has been identified – almost all of them in Southern or Central America, except for the Pacific island nation of Samoa and Cape Verde, off the north-west African coast.

All other travellers are advised to take precautions to avoid being bitten by mosquitos, including wearing repellent, wearing long sleeves, and using buildings equipped with insect screens and air conditioning.

The Health Department has issued advice for clinicians to consider the possibility of Zika virus infection in patients returning from affected areas, and said authorities were ready to act if it appeared in areas where mosquitos capable of transmitting it were present.

“In the event of an imported case in areas of Queensland where the mosquito vector is present, health authorities will respond urgently to prevent transmission, as they do for dengue,” the Department said.

Adrian Rollins

AMA in the News – 2 February 2016

Your AMA has been active on policy and in the media on a range of issues crucial to making our health system better. Below is a snapshot of recent media coverage.

Print/Online

Timing of Medicare cuts announcement criticised, The Age, 29 December 2015
Doctors have criticised the Turnbull government for using the Christmas-New Year holiday period to reveal the first tranche of items to be dropped from the government-subsidised Medicare Benefits Schedule. AMA President Professor Brian Owler said the proposed cuts would make the common tonsillectomy procedure marginally more expensive due to fewer individual parts of the operation being funded by Medicare.

Take care morning after the big night, Adelaide Advertiser, 1 January 2016
Health and safety experts are urging people to be careful embracing life the morning after a big night. AMA President Professor Brian Owler urged people to take it easy with water sports and even sunbaking over summer if they have consumed alcohol.

Anti-vax nuts try to cheat jab laws, The Sunday Telegraph, 3 January 2016
Anti-vaxers are trying to manipulate the new “no jab no pay” laws in a bid to gain taxpayer-funded rebates available only to those who vaccinate their children. AMA President Professor Brian Owler said the attempt is hurting only the child involved.

Threats to handouts prompts jab boosts, The Sunday Telegraph, 17 January 2016
Doctors have noticed a significant boost in the number of parents bringing their children in for vaccinations as the new “No Jab, No Play” laws start to bite. AMA President Professor Brian Owler said the laws were already having a beneficial effect on immunisation numbers.

Warning over autism doctor shopping, The Australian, 19 January 2016
GPs should be given stronger guidance about how to diagnose autism. AMA President Brian Owler said that having consistent guidelines would make things easier for doctors during diagnosis, but added that the emphasis should remain on assessing children early.

Doctors warn of busy emergency facilities, Australian Financial Review, 28 January 2016
The AMA Public Hospital Report Card found the performance of the public hospital system has stagnated, and even declined in some areas. AMA President Professor Brian Owler placed the blame for the declining public hospital performance firmly on the Federal Government’s reduced rate of health funding which would lead to a funding “black hole” in 2017.

Hospitals faced with funding ‘black hole’, Sydney Morning Herald, 28 January 2016
The Federal Government is under pressure to reform taxes following a report card on public hospitals that shows the most urgent patients are waiting longer at emergency departments. AMA President Professor Brian Owler said hospitals would be insufficiently funded to meet the rising demands from 2017, when the states and territories were facing a “black hole”.

State looks sick, Herald Sun, 29 January 2016
Victorian emergency patients are paying the price for a “funding crisis” in the nation’s public hospitals, and doctors warn the worst is yet to come. The AMA warned that a further $57 billion of Commonwealth funding was expected to be lost from hospital coffers over seven years starting next year, by indexing funding growth to CPI and population expansion.

Radio

Professor Brian Owler, 774 ABC Melbourne, 29 December 2015
AMA President Professor Brian Owler discussed recent cuts to the Medicare Benefits Scheme. Professor Owler said it was clearly a cost saving exercise by the Federal Government.

Professor Brian Owler, Radio National, 29 December 2015
AMA President Professor Brian Owler talked about new cuts to the MBS. Professor Owler said the AMA has supported the Medicare Benefits Schedule review from the outset, on the basis there were no cuts to access to patient services.

Dr Stephen Parnis, 4BC Brisbane, 7 January 2016
AMA Vice President Dr Stephen Parnis dismissed claims that pap smears would cost women $30. Dr Parnis said cuts to Medicare have resulted in reports of overpriced pap smears.

Dr Stephen Parnis, Tipple J Sydney, 25 January 2016
AMA Vice President Dr Stephen Parnis discussed the use of so-called “hangover clinics”. Dr Parnis said the treatments they offered were a placebo, and he questioned whether their operations were ethical.

Professor Brian Owler, Radio National, 28 January 2016
AMA President Professor Brian Owler discussed the latest AMA Public Hospital Report Card which revealed a public hospital funding ‘black hole’ as Commonwealth funding cuts hit the States and Territories.

Professor Brian Owler, 2GB Sydney, 28 January 2016
AMA President Professor Brian Owler talked about a report from the AMA showing emergency department waiting times has worsened for the first time in seven years.

Professor Brian Owler, 774 ABC Melbourne, 28 January 2016
AMA President Professor Brian Owler talked about the AMA Public Hospital Report Card and said longer waits for elective surgery and emergency rooms often resulted in more health problems.

Television

Professor Brian Owler, ABC News 24, 28 December 2015
AMA President Professor Brian Owler talked about Health Minister Sussan Ley’s proposed removal of 23 items from the Medicare Benefits Schedule.

Dr Stephen Parnis, ABC News 24, 1 January 2016
AMA Vice President Dr Stephen Parnis talked about how parents who refused to vaccinate their children would be stripped of childcare benefits by the Federal Government under new laws. Dr Parnis said public health was a major government responsibility, and vaccination rates were not as high as health experts would like them to be.

Professor Brian Owler, The Today Show, 14 January 2016
AMA President Professor Brian Owler discussed the importance of safe work environments for emergency workers after a police officer was allegedly shot by a patient with a history of ice addiction at a Sydney hospital.

Professor Brian Owler, Channel 7 Melbourne, 26 January 2016
Medibank says it is passing savings onto its members, but there are concerns more affordable premiums might mean cuts in benefits. AMA President Professor Brian Owler said doctors did not want to see people taking out cheaper premiums and policies and then realising that their private health insurance was not worth it.

Professor Brian Owler, The Today Show, 28 January 2016
The AMA Public Hospital Report Card 2016 showed that, against key measures, the performance of public hospitals is virtually stagnant, and even declining in key areas. AMA President Brian Owler said unless the Government looked at the way it funded public hospitals, people were likely to wait longer in emergency departments and for elective surgery.

Professor Brian Owler and Dr Stephen Parnis, Channel 9, 28 January 2016
The AMA released its new Public Hospital Report Card and the figures revealed that scores of patients were not being treated within recommended times. Doctors fear the situation is only going to get worse.

Professor Brian Owler, ABC News 24, 28 January 2016
The AMA has warned that public hospitals are facing a funding crisis. AMA President Professor Brian Owler said hospitals faced a crisis due to the funding fight between Federal and State governments.

Hospitals face funding ‘black hole’

Almost a third of Emergency Department patients in need of urgent treatment are being forced to wait more than 30 minutes to be seen, while thousands of others face months-long delays for elective surgery as under-resourced public hospitals struggle to cope with increasing demand.

The AMA’s latest snapshot of the health of the nation’s public hospital system shows that improvements in performance have stalled following a sharp slowdown in Federal Government funding, underlining doctor concerns that patients are paying a high price for Budget austerity.

“By any measure, we have reached a crisis point in public hospital funding,” AMA President Professor Brian Owler said. “The states and territories are facing public hospital funding black hole from 2017 when growth in Federal funding slows to a trickle.”

The Federal Government will have slashed $454 million from hospital funding by 2017-18, and a downshift in the indexation of spending from mid-2018 will reduce its contribution by a further $57 billion by 2024-25.

Professor Owler said the consequences of Commonwealth cutbacks were already showing up in hospital performance, and the steep slowdown in funding growth in coming years will further exacerbate the situation.

“Public hospital funding is about to become the single biggest challenge facing State and Territory finances, and the dire consequences are already starting to show,” the AMA President said. “Without sufficient funding to increase capacity, public hospitals will never meet the targets set by governments, and patients will wait longer for treatment.”

The AMA’s Report Card, drawing on information from the Australian Institute of Health and Welfare, the Council of Australian Governments Reform Council and Treasury, shows the performance of public hospitals against several key indicators has plateaued and, by some measures, is declining.

In terms of hospital capacity, the long-term trend toward fewer beds per capita is continuing. The decline is even more marked when measured in terms of the number of beds for every 1000 people aged 65 years of older – a fast growing age group with the highest demand for hospital services.

In 1993 there were almost 30 beds for every 1000 older people, but by 2013-14 that had virtually halved to around 17 beds.

Alongside a relative decline in capacity, there are signs the hospitals are struggling under the pressure of growing demand.

Emergency departments, often seen as the coal face of hospital care, the proportion of urgent Category 3 patients seen within the clinically recommended 30 minutes fell back to 68 per cent in 2014-15 – a two percentage point decline from the previous year, and a result that ended four years of unbroken improvement.

The national goal that 80 per cent of all ED patients are seen within clinically recommended times appears increasingly unlikely, as does the COAG target that 90 per cent of all ED patients be admitted, referred or discharged within four hours. For the last two years, the ratio has been stuck at 73 per cent.

The outlook for patients needing elective surgery is similarly discouraging.

The AMA report found that although there was slight reduction in waiting times for elective surgery in 2014-15, patients still faced a median delay of 35 days, compared with 29 days a decade earlier.

It appears very unlikely the goal that by 2016 all elective surgery patients be treated within clinically recommended times will be achieved. Less than 80 per cent of Category 2 elective surgery patients were admitted within 90 days in 2014-15 – a figure that has barely budged in 12 years.

The Commonwealth argues it has had to wind back hospital spending because of unsustainable growth in the health budget.

But Professor Owler said the evidence showed the opposite was the case.

The Government’s own Budget Papers show total health expenditure grew 1.1 per cent in 2012-13 and 3.1 per cent the following year – well below long-term average annual growth of 5 per cent.

Furthermore, health is claiming a shrinking share of the total Budget. In 2015-16, it accounted for less than 16 per cent of the Budget, down from more than 18 per cent a decade ago.

“Clearly, total health spending is not out of control,” Professor Owler said, and criticised what he described as a retreat by the Commonwealth Government from its responsibility for public hospital funding.

“There is no greater role for governments than protecting the health of the population,” he said. “Public hospitals are the foundation of our health care system. Public hospital funding and improving hospital performance must be a priority for all governments.”

In a statement to Fairfax Media, Health Minister Sussan Ley declined to specifically address the issues raised in the AMA Report Card.

Instead, the Minister pointed out that Commonwealth funding for hospitals was increasing on an annual basis, and there had been no policy anouncements in last year’s Budget or MYEFO affecting that. While technically correct, the Minister’s comments brush over the big changes announced in the first Hockey BUdget in 2014-15, including a massvie slowdown in the growth of Federal funding for hospitals.

The issue of hospital funding is set to loom large when the nation’s leaders meet in March to discuss reform of the Federation.

Already, several premiers are pushing for an overhaul of taxation arrangements to provide the states with a better growth revenue stream than the Goods and Services Tax.

South Australian Premier Jay Weatherill has proposed that the Commonwealth hold on to GST revenue and, in return, give the states and territories a slice of income tax receipts.

Adrian Rollins

[Perspectives] The judgment dilemma

Samuel Shem’s satirical novel House of God (1978) placed a magnifying glass on the callousness of medical training and hospital life. Although he exaggerated the toxic nature of the physician–patient relationship, he captured startling elements of hospital culture, such as physicians’ use of phrases like “lol in nad” (little old lady in no apparent distress) and “gomer” (get out of my emergency room)—terms that are still a part of the medical lexicon. House of God also exposed physicians’ tendency to make judgments about patients seconds after meeting them.

Sepsis early intervention saves lives, NSW study finds

An emergency room program that helps speed up the time it takes for patients to be treated with sepsis has been found to be successful.

The ‘SEPSIS KILLS’ program aims to reduce sepsis deaths by recognising the condition early and managing it promptly.

The program was introduced in 2011 to 97 NSW emergency departments and data from 13 567 patients were collected for the period 2011–2013.

According to research published in today’s Medical Journal of Australia, the sepsis death rate decreased from 20% in 2009 – 2011 to 14.1% in 2013 thanks to the introduction of the program.

Sepsis was involved in 17.5% of in-hospital deaths in 2009 in NSW and is one of the most common causes of clinical deterioration, causing more deaths than prostate cancer, breast cancer and HIV/AIDS combined.

Related: Act fast on sepsis

Authors Mary Fullick, Sepsis Program Lead at the Clinical Excellence Commission (CEC) in Sydney, Professor Mary-Louise McLaws, at the University of New South Wales, and colleagues wrote in the paper: “The focus of the program is to recognise risk factors, signs and symptoms of sepsis; resuscitate with rapid intravenous fluids and antibiotics; and refer to senior clinicians and teams.”

Since 2011, the changes include:

Proportion of patients receiving intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009–2011 to 52.2% in 2013
The percentage for whom a second litre of fluid was started within 60 minutes rose from 10.6% to 27.5%.
The number of sepsis patients being treated immediately had increased from 2.3% in 2009 to 4.2% in 2013.
The number of patients treated within 10 minutes of arrival increased from 40.7% in 2009 to 60.7% in 2013.
There were also significant declines in time in intensive care and total length of stay.

As a result, NSW public hospitals have begun extending the SEPSIS KILLS program to inpatient areas and have introduced a 48-hour management plan for ward patients.

The authors conclude: By focusing on the principles of “Recognise, Resuscitate, Refer” it is possible to reduce the time it takes to start antibiotics and fluid resuscitation. This program could be applied in other jurisdictions and its integration with antimicrobial stewardship requirements should be considered.”

Read the research in the Medical Journal of Australia.

Latest news:

SEPSIS KILLS: early intervention saves lives

The increasing incidence of sepsis is well recognised, and is generally attributed to the growing prevalence of chronic conditions in ageing populations.1–3 In New South Wales, the number of patients with a diagnosis of sepsis in the Admitted Patient Data Collection (APDC) has increased, and sepsis was involved in 17.5% of in-hospital deaths in 2009, compared with a mortality of 1.5% for all hospital separations (unpublished data).

The clinical presentation of sepsis may be subtle; fever is not always present.4,5 In NSW, failure to recognise and respond to sepsis has been regularly reported. In 2009, 167 incidents were highlighted in a clinical focus report published by the Clinical Excellence Commission (CEC).6 A Quality Systems Assessment in 2011, completed by over 1500 respondents across the NSW hospital system, reported that 34% of clinical units did not have guidelines or protocols for managing sepsis.7

This article reports on the SEPSIS KILLS program of the CEC, which aims to promote the skills and knowledge needed for recognising and managing patients with sepsis in NSW hospital emergency departments.

Methods

The focus of the program is to RECOGNISE risk factors, signs and symptoms of sepsis; RESUSCITATE with rapid intravenous fluids and antibiotics; and REFER to senior clinicians and teams. Standardised sepsis tools were developed in consultation with NSW emergency physicians, and included adult and paediatric pathways that built on the NSW deteriorating patient system, Between the Flags (BTF).8 The vital signs assessed in the sepsis pathways were consistent with BTF, and varied marginally from accepted systemic inflammatory response criteria (Box 1).

The SEPSIS KILLS pathways promote bundles of care, with the emphasis on early intervention. The adult bundle includes taking blood cultures, measuring serum lactate levels, administering intravenous antibiotics within an hour of triage and recognition, and administering a fluid bolus of 20 mL/kg, followed by another bolus of 20 mL/kg (if necessary) and inotropic drugs if the patient’s condition is not fluid-responsive. If no improvement is observed, senior medical review and admission to intensive care or retrieval to a major centre should be considered (Box 2). The paediatric bundle emphasises the importance of early senior clinical review and decision making. In addition, an empiric antibiotic guideline was developed with advice from expert infectious disease physicians. Emphasis was placed on the first dose of antibiotics, thereby allowing time for further assessment and diagnosis. Because of wide variations in practice, the guideline also contained details on how antibiotics could be administered most expeditiously.

The program was implemented in 2011 with a top-down, bottom-up approach, with strong leadership from medical and nursing clinical leads, and supported by the local health district Clinical Governance Units. Participation was not mandatory, and no extra resources were provided to participating emergency departments who implemented the program. The CEC team supported clinicians by holding a preliminary launch, monthly CEC–hospital teleconferences, executive reports, newsletters, site visits and workshops. A range of online resources was provided, including a Sepsis Toolkit (implementation guide) and various education tools.

Emergency departments were encouraged to collect prospective data on paediatric and adult patients with a provisional diagnosis of sepsis who had received intravenous antibiotics. An online sepsis database (from August 2011) facilitated collection of a minimum dataset for each patient that included their date of birth, triage time and date, triage category, clinical observations (including systolic blood pressure [SBP] and serum lactate levels), time and date of initial intravenous antibiotic treatment and of commencement of the second litre of intravenous fluid, the presumptive source of sepsis, and the disposition of patients following emergency department treatment. Data were collected either prospectively or by retrospective chart review. The database allowed emergency departments to monitor time to antibiotics and fluids in real time, and to compare this with the corresponding local health district and NSW data.

Ethics approval was obtained from the NSW Sepsis Register, which was developed as a public health and disease register under s98 of the Public Health Act 2011. The Sepsis Register is maintained by the CEC.

Data analysis

Analysis of process measures (time to antibiotic, time to intravenous fluid) was based on data from the SEPSIS KILLS database. A total of 13 567 SEPSIS KILLS records were submitted for linkage to the APDC to assess associations between in-hospital mortality and sepsis severity and patient disposition. Patients were classified by emergency department staff according to the Australasian Triage Scale (ATS).9 The cases were further classified as being severe or uncomplicated sepsis according to the serum lactate levels and presenting SBP of the patient.

To assess the population-level impact of the SEPSIS KILLS program, we analysed health outcomes (in-hospital mortality, hours in intensive care, length of stay) for paediatric and adult patients separated from NSW hospitals with ICD-10-AM (International Classification of Diseases, 10th revision, Australian modification) discharge diagnosis codes consistent with sepsis10 recorded in the Admitted Patient, Emergency Department Attendance and Deaths Register. This register was accessed through the NSW Ministry of Health Secure Analytics for Population Health Research and Intelligence (SAPHaRI) system. Linkage was undertaken by the Centre for Health Record Linkage (CHeReL). Only patients admitted to public hospitals with emergency departments were included in the analysis. Trend analysis was performed for the run-in period, August 2009 – December 2011, and for the two following years, 2012 and 2013. Outcomes by sepsis severity could not be analysed at the population level because of the lack of consensus about using ICD-10-AM codes to differentiate between severe and uncomplicated sepsis.

Descriptive and inferential analyses included the calculation of frequencies, odds ratios (ORs) and 95% confidence intervals, and χ² tests for trends. Trends over time for process and outcome measures were assessed in regression models. Logistic regression was used to analyse in-hospital deaths, while linear regression models were used for time in intensive care and lengths of stay. Models were adjusted as appropriate for covariates (age, year, triage category and severity of sepsis). Statistical significance was defined as P < 0.05.

Results

The SEPSIS KILLS program was implemented as individual emergency departments became ready during 2011. Both retrospective and prospective data were collected by 97 hospitals to 31 December 2013 and entered into the sepsis database. Data were submitted by 13 tertiary, 19 metropolitan and 65 rural hospitals. Because of the low number of paediatric patients, analysis was restricted to data for adult patients.

The provisional sources of sepsis included the lungs (5216 patients, 40.5%), urinary tract (2998, 23.2%), abdomen (1077, 8.4%), skin or soft tissue (975, 7.6%), musculoskeletal system (98, 0.8%), central nervous system (96, 0.7%), vascular device (82, 0.6%), and other systems (973, 7.6%). For 1238 patients (9.6%) the source was unidentified, for 133 (1.0%) no source was recorded.

There were age data in 12 879 records. There was a significant reduction in the mean age of patients between 2009 and 2013, from 67.3 years in 2009–2011 to 64.8 years in 2013 (P < 0.001 for trend; Box 3).

Data for the process indicators from the CEC sepsis database are summarised in Box 3. The proportion of patients who were categorised at triage as ATS 1 (“see immediately”) rose from 2.3% in 2009–2011 to 4.2% in 2013. Those categorised as ATS 2 (“see within 10 minutes”) increased from 40.7% in 2009–2011 to 60.7% in 2013 (P < 0.001). There were small reductions in the proportions of patients classed as ATS 3, 4 or 5.

The proportion of patients who received antibiotics within 60 minutes of triage or recognition increased from 29.3% in 2009–2011 to 52.2% in 2013 (linear trend test, P < 0.001). Similarly, the number of patients who started a second litre of intravenous fluid within one hour rose from 10.6% to 27.5% (linear trend test, P < 0.001).

The analysis of population-based APDC data, which included all separations with emergency department involvement from public hospitals in NSW between January 2009 and December 2013, is presented in Box 4. There were 15 801 sepsis hospital separations during the run-in period of 2009–2011, with a mortality of 19.3%. This rate declined to 17.2% in 2012 and 14.1% in 2013. There was a significant linear decrease over time (P < 0.0001); the OR for death (compared with the run-in period) was 0.87 (95% CI, 0.80–0.94) in 2012, and 0.69 (95% CI, 0.63–0.74) in 2013. Significant linear declines were also observed for time in intensive care and length of stay (for each trend: P < 0.0001).

Linkage of the APDC and sepsis databases showed that the mortality rate for the 1616 patients with severe sepsis (serum lactate ≥ 4 mmol/L or SBP < 90 mmHg) was 19.7%; these patients were significantly more likely to die than patients with uncomplicated sepsis (serum lactate < 4 mmol/L and SBP ≥ 90 mmHg) (OR, 3.7; 95% CI, 3.2–4.4; P < 0.0001). The mortality rate for the 893 patients with hyperlactataemia (a lactate level of 4 mmol/L or more; reference interval, 0.5–2.0 mmol/L) was 24.9%, while that for 637 patients presenting with cryptic shock — hyperlactataemia together with normotension (SBP ≥ 90 mmHg) — was 21.2%. There was no change in mortality for either group over time. For 734 patients who presented with SBP < 90 mmHg and lactate levels < 4 mmol/L, mortality was 13.5%, which declined significantly across the study period (2009–2011, 16.5%; 2012, 16.0%; 2013, 9.8; P = 0.03). The overall mortality rate for uncomplicated sepsis patients increased significantly over time: 3.7% (21/567) in 2009–2011, 6.2% (145/2336) in 2012, and 6.7% (145/2164) in 2013 (P = 0.02).

The mortality rate for the 268 ATS 1 patients was 28.8%. The risk of death for patients over 65 years of age was 3.3 times higher (95% CI, 2.6–4.1) than for patients under 65 years of age (P = 0.001).

The mortality rate for 543 severe sepsis patients admitted to intensive care did not change significantly over time — 23.4% (2009–2011), 19.5% (2012) and 16.0% (2013) (P = 0.145) — nor did the proportion of the 1073 patients with severe sepsis who were admitted to the ward and died — 21.4% (2009–2011), 21.5% (2012) and 18.4% (2013) (P = 0.263). In contrast, the risk of death for 4225 patients with uncomplicated sepsis admitted to the ward increased significantly: 3.2% (15/466) during 2009–2011, 6.0% (115/1914) during 2012, and 6.2% (115/1845) during 2013 (P = 0.047).

Discussion

SEPSIS KILLS is a quality improvement program that aims to reduce preventable harm to patients with sepsis by recognising the condition early and managing it promptly. It is based on the principle that early recognition and aggressive management with antibiotics and fluids will improve outcomes.11–13 It is consistent with the 3-hour component of the resuscitation bundle outlined in the international guidelines of the Surviving Sepsis Campaign.3

The program was not planned as a before-and-after project, but was independently implemented by individual emergency departments during 2011. More than 80% of NSW emergency departments (175 of 220) used the sepsis pathways, and 97 emergency departments submitted over 13 000 records. The resulting increase in the number of patients for whom antibiotics were initiated within 60 minutes of recognition and the increased likelihood of the second litre of fluids being started in the first hour indicate that the program was successful. Greater urgency is also apparent from the marked increase in the number of patients classified at triage as ATS 2. We cannot, however, explain the significant age difference between the patients seen in 2012 and 2013.

Reviewing the population-based APDC hospitalisations with an ICD-10-AM code for sepsis showed that there was a steady reduction in mortality over time. Contrary to what we expected, the survival benefit in our patients appears to have been greatest for those with evidence of haemodynamic instability (SBP < 90 mmHg) but normal lactate levels.

The mortality rate of 15%–20% for patients admitted to intensive care with severe sepsis (one-third of the overall sample) is consistent with the overall mortality rate in Australian and New Zealand intensive care units.14,15 In 2013, the crude mortality rate for the patients admitted to wards was higher than that for the intensive care group. We believe the relatively high proportion of ward patients may be the result of an underappreciation of the potential mortality of sepsis, of the significance of elevated lactate levels, and of the time course of the septic process, as well as of failure to recognise cryptic shock16 and the obvious and practical problem of intensive care unit bed availability. We did not assess how many had end-of-life treatment limitations in place.

Managing large numbers of patients with sepsis on the wards has been described elsewhere.17,18 These patients have not been well studied, although a number of studies have identified deficiencies in care.19–21 The significant increase in mortality among patients with uncomplicated sepsis admitted to the ward causes concerns that some of our ward patients may have qualified for intensive therapy. An increase in mortality in less severe sepsis has also been documented by other authors.22

The major challenge was managing the prescribing of antibiotics. Despite general acceptance of expert guidelines for prescribing antibiotics, differences in their prescription and administration were observed. This evidence–practice gap is well recognised,23 and the empiric antibiotic guideline was developed to promote appropriate antibiotic prescribing practices and optimal outcomes.24 The empiric guideline was consistent with the principles of antimicrobial stewardship, and, while each site was allowed to modify it according to local opinion and antibiotic resistance patterns, changes were infrequent. Particular anxieties were expressed about prescribing and administering gentamicin. The administration component of the guideline was developed to promote the most expeditious method of administration rather than favouring the slow infusion that had become normal practice. Despite the emphasis on the first dose and timely review, antibiotics were often continued long after they should have been reviewed, following consideration of the results of pathology investigations.

Other challenges beyond our control included educating a high turnover workforce in emergency departments, as well as medical engagement, particularly in rural facilities where governance is difficult and there is no doctor on site, or locum medical staff are more common. There were wide variations in the methods of blood culture collection, and a standardised guideline for blood cultures was subsequently added to the Sepsis Toolkit.

Limitations

This work is subject to the limitations of any quality improvement project at multiple sites. The prolonged run-in period was not ideal. Our approach was not to measure compliance with the care bundle, as undertaken elsewhere, but to use time as a measure for promoting behavioural change among emergency department clinicians. Assessing patient outcomes was the major difficulty. The voluntary nature of data collection resulted in its inconsistent submission, and the lack of strict diagnostic criteria for sepsis resulted in patients with conditions from across the inflammatory condition–sepsis spectrum being included in the SEPSIS KILLS database. Resource limitations also meant that some sites implemented the pathways but did not submit data.

Reviewing the outcomes of patients with an ICD-10-AM code for sepsis in the population-based administrative APDC is an accepted approach. This, however, entails the risk of reviewing the outcomes of a different group of patients, a group for whom the final diagnosis might not be directly related to sepsis or its severity. This is a potential problem when comparing the final diagnosis in the APDC database with the provisional diagnosis in the SEPSIS KILLS data.

Finally, the improved outcomes described in our article may be the result of the SEPSIS KILLS program, but may also be related to other initiatives for improving quality of care.

Implications for clinicians, researchers and policy makers

The observation that patients with severe sepsis are being managed on the wards highlights the need for a shift in the focus of both practice improvement and research from intensive care to ward management. It also raises the problem of sepsis and the deteriorating patient. We informally estimated that around 30% of patients who required a Rapid Response call had sepsis, but this may be an underestimate, with rates possibly as high as 50%–60%.25 Finally, our work confirms the need for continued research into risk stratification tools for sepsis in the emergency department. In the meantime, all patients with lactate levels of 4 mmol/L or greater require intensive care unit review and admission.

The SEPSIS KILLS program promotes early recognition and management of sepsis during the first few hours in NSW emergency departments. By focusing on the principle of “Recognise, Resuscitate, Refer” it is possible to reduce the time before antibiotics are administered and fluid resuscitation initiated. This program could be applied in other jurisdictions and its integration with antimicrobial stewardship requirements should be considered.

Box 1 –
The SEPSIS KILLS pathway for adult patients in hospital emergency departments, page 1

Box 2 –
The SEPSIS KILLS pathway for adult patients in hospital emergency departments, page 2

Box 3 –
Characteristics, and process and outcome indicators of sepsis-related hospital separations before and after the launch of the SEPSIS KILLS program

Characteristics	Run-in period	SEPSIS KILLS program in operation		P for trend
Characteristics	Aug 2009 – Dec 2011	2012	2013	P for trend

Number of separations	1585	5396	5905
Mean age ± SEM, years	67.3 ± 0.5	67.6 ± 0.3	64.8 ± 0.3	< 0.001
Triage category*				< 0.001
1	37 (2.3%)	176 (3.3%)	242 (4.2%)
2	463 (40.7%)	2765 (51.5%)	3532 (60.7%)
3	683 (43.2%)	2034 (37.9%)	1767 (30.4%)
4	207 (13.1%)	378 (7.0%)	267 (4.6%)
5	10 (0.6%)	16 (0.3%)	12 (0.2%)
Missing data	5	22	83
Antibiotic received within 60 min	464 (29.3%)	2165 (40.2%)	3083 (52.2%)	< 0.001
Second litre of intravenous fluid within 60 min	135 of 1272 patients (10.6%)	521 of 3631 patients (14.3%)	991 of 3609 patients (27.5%)	< 0.001

SEM = standard error of the mean.

Box 4 –
Hospital outcomes prior to and after the launch of the SEPSIS KILLS program, NSW, January 2009 to December 2013

Outcomes	Descriptive statistics	Odds ratio (95% CI)	P for trend

Deaths, numbers (percentage)			< 0.0001
2009–2011	3053/15 801 (19.3%)	1
2012	979/5683 (17.2%)	0.87 (0.80–0.94)
2013	870/6167 (14.1%)	0.69 (0.63–0.74)
Mean time in intensive care (SEM), hours			< 0.0001
2009–2011	32.7 (1.0)
2012	26.6 (1.4)
2013	25.8 (1.3)
Mean length of stay (SEM), days			< 0.0001
2009–2011	13.5 (0.1)
2012	12.2 (0.2)
2013	11.5 (0.2)

SEM = standard error of the mean. Source: Admitted Patient Data Collection, NSW Ministry of Health Secure Analytics for Population Health Research and Intelligence (SAPHaRI). Data extracted on 1 June 2015.

Guns in hospitals ‘a very bad idea’: AMA President

Knee-jerk calls to arm hospital security guards with guns following a double-shooting at Nepean Hospital would be “a very dangerous path to go down”, AMA President Professor Brian Owler has warned.

Speaking after a violent attack in which a drug-affected patient managed to get hold of a gun during a struggle with a police officer and security guards at the Nepean Hospital’s emergency department, Professor Owler said that although security arrangements should be reviewed in light of the incident, bringing more guns into hospitals was not the answer.

“Calls for people to be armed in our emergency departments, I think, is a very bad way to go,” he said. “We need less guns, not more, in our society and, as we saw through this incident, it actually raises the dangers for people, including the doctors, nurses and other patients.”

The Sydney Morning Herald has reported that the shooter was a 39-year-old former nurse who had ongoing problems with the drug ice.

According to the report, the man had been arrested earlier in the day, and was taken to Nepean Hospital on Tuesday evening after sustaining injuries including a suspected broken jaw.

While at the hospital’s emergency department, it is alleged he threatened a female doctor, prompting police to be called. When the first officer on the scene, Senior Constable Luke Warburton, attempted to arrest the man, a scuffle broke out during which the man seized the police officer’s gun and fired two shots, hitting Senior Constable Warburton and a security guard, before being subdued.

Senior Constable Warburton was left in a critical condition after being shot in the upper thigh, but was later stabilised. The security guard was shot in the leg and was listed as being in a stable condition.

The man has been charged with shooting with intent to murder, discharging a firearm to resist arrest, and detaining for advantage.

Professor Owler said the incident was “very alarming”, and highlighted both the influence of the drug ice in increasing the risk of violence in emergency departments, and the dangers of having guns in hospitals.

The AMA President said that although assaults and attacks in hospital emergency departments was not a new problem, “ice has really raised the level to a greater height…the drug really causes people to be very difficult to control, particularly when they’re in these episodes of psychosis”.

He said it was not uncommon for doctors and nurses to need the help of hospital security guards in helping to control, and occasionally to restrain, such patients until they could be sedated.

But Professor Owler said guns were not the answer.

“We need to…review the security, particularly [to] make sure that there are ample security guards in our emergency departments, and that there are Rapid Response teams that can subdue people when they are in these sorts of situations,” he said.

But he warned that arming security guards would be “a very dangerous path to go down, and I think this incident illustrates exactly why that is.

“What we need to do is make sure that we have ample security, that we have the proper resources so that we can protect our doctors and nurses.

“That doesn’t mean more guns, we need to look at other ways that we can protect them.”

Adrian Rollins

Thousands of doctors join NHS strike

Around 45,000 junior doctors are estimated to have gone on strike across England as part of a stand-off with the British Government over proposed changes to contracts they believe will lead to unsafe work hours that will compromise patient safety.

Striking doctors established picket lines outside more than 100 National Health Service hospitals and clinics, according to the British Medical Association, in the first such industrial action in more than 40 years.

The NHS reported that 1279 inpatient operations and 2175 outpatient services have been cancelled as a result of the strike, while thousands of junior doctors honoured a commitment to attend work to ensure that accident and emergency departments were not affected by the protest.

NHS England said that 39 per cent of junior doctors had reported for duty – a fact seized on by Health Secretary Jeremy Hunt to imply that the industrial action did not have widespread support.

The NHS said that altogether 71 per cent of rostered staff, including junior doctors, other doctors and consultants, had showed up for work.

NHS England National Incident Director Anne Rainsberry said the strike had nonetheless “caused disruption to patient care, and we apologise to all patients affected. It’s a tough day, but the NHS is pulling out all the stops, with senior doctors and nurses often stepping in to provide cover”.

But the BMA said it was misleading of Mr Hunt to claim the strike was a flop because so many junior doctors had reported for work.

“Since we asked junior doctors who would be covering emergency care to go into work today, it is hardly surprising that they have done so, along with those who are not members of the BMA,” a BMA spokesman told the Daily Mail. “The simple fact is the Government cannot ignore the thousands who have today made it quite clear what they think of the Government’s plans.”

Several hospitals and NHS trusts placed striking doctors on a ‘black alert’, claiming they were operating under emergency conditions because an influx of cases.

Sandwell Hospital in West Bromwich declared a level 4 incident and directed striking junior doctors to return to work.

But the BMA condemned such declarations as a ploy to try to thwart the protest.

BMA Chair Dr Mark Porter said doctors had given the NHS ample warning of the impending strike to ensure hospitals could make adequate preparations and minimise the disruption to patients, such as by deferring scheduled surgery and consultations.

Striking doctors in several locations reported there were no obvious circumstances that warranted emergency declarations by their local NHS, and said that although they were equipped and prepared to abandon the strike at a moment’s notice if their services were required, they would continue to take industrial action until that time.

The doctors are striking over a plan by the Government to force them on to contracts which would increase requirements to work long shifts, including on weekends and out-of-hours. They claim there are inadequate safeguards against unsafe working hours, potentially compromising patient care and safety, while the BMA declared an in-principle objection to the Government’s aim of removing the distinction between weekend and after-hours work and the rest of the working week.

Mr Hunt said numerous studies had shown that people received lesser care on weekends than they did during the week, and “I can’t, in all conscience as Health Secretary, sit and ignore those studies”.

“We have to do something about this. People get ill every day of the week,” the Minister said, and criticised the strike as “wholly unnecessary”.

But one of the striking doctors, emergency medicine consultant Dr Rob Galloway, said the Government had left doctors with no option but to take industrial action.

Writing in the MailOnline, Dr Galloway said there was “no doubt” that junior doctor contracts needed reform, and there needed to be improvements in handling unscheduled care on weekends.

But he said that the Government, through the approach it had taken, had squandered what would have been strong support for reform.

Alongside attacks that called the commitment and integrity of doctors into question, Dr Galloway said the Government’s offer amounted to an effective pay-cut for out-of-hours work, making it even harder for hospitals to recruit and retain staff.

“If you want to improve weekend care, why on earth would you impose a pay cut for staff doing this vital weekend work, pushing them out of the NHS? The new contract as it stands will make things worse, and lead to a recruitment and retention crisis.”

The World Medical Association had thrown its support behind the junior doctors.

WMA President Sir Michael Marmot said the peak international medical organisation recognised the right of doctors to take action to improve working conditions that may also affect patient care.

“In this case, it is clear that patient care would suffer in the long term if the Government’s proposals to change the working hours of junior doctors goes ahead,” Sir Michael said, adding that the doctors had received widespread support from the public and NHS colleagues.

He urged the Government to “establish a new working relationship with junior doctors. It is essential that trust is restored on both sides, for the sake of patient care”.

The 24-hour strike is due to end this evening, Australian Eastern Standard Time.

Unless the dispute is resolved, further strikes are planned for 26 January and 10 February.

Adrian Rollins

Picture credit: William Perugini / Shutterstock.com

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